Delayed Facial Paralysis following Uneventful KTP Laser Stapedotomy: Two Case Reports and a Review of the Literature

Abstract

Facial palsy that occurs immediately after middle ear surgery (stapedectomy, stapedotomy, and tympanoplasty) can be a consequence of the local anesthetics and it regresses completely within a few hours. In the case of delayed facial palsy, the alarming symptom occurs several days or even weeks after uneventful surgery. The mechanism of the neural dysfunction is not readily defined. Surgical stress, intraoperative trauma, or laceration of the chorda tympani nerve with a resultant retrograde facial nerve edema can all be provoking etiological factors. A dehiscent bony facial canal or a multiple microporotic fallopian canal (microtrauma or laser effect) can also contribute to the development of this rare phenomenon. The most popular theory related to the explanation of delayed facial palsy at present is the reactivation of dormant viruses. Both the thermal effect of the laser and the elevation of the tympanomeatal flap can reactivate viruses resting inside the ganglion geniculi, facial nerve, or facial nuclei. The authors report the case histories of a 55-year-old female, and a 45-year-old male who presented with a delayed facial palsy following laser stapedotomy. The clinical characteristics, the therapeutic options, and the possibility of prevention are discussed.

Typical or Atypical Ramsay-Hunt Syndrome in Delayed Facial Palsy After Stapedectomy?

“…(1/503) Zohar Y et al [21] J [6] Medicine, 2014 (2/149) 42, M R 13 no pain, slight pain * 3 days before DFP onset; n.s. = not specified; n.p.= not performed A surgical re-exploration of the middle ear was not deemed useful nor was the decompression of the Fallopian canal up to its labyrinthine segment through a combined approach, as proposed in the past by some authors [26] .…”

“…II -60 I Salvinelli F. et al [5] yes HSV- 1 IgM in 1 patient II acyclovir 30 I yes III 30 I yes II 30 I yes III 55 II yes III 270 I yes IV 30 I yes IV 30 I yes IV 20 I Cohen M et al [7] no n.p. VI Steroids (prednisone) 86 I no n.p VI and antiviral >10 I Révész P, et al [6] suspected virus II Steroids 36 I reactivation by heat III (methylprednisolone) 43 I and antiviral Steroids (medrol) and antiviral months, when it reached grade II, then stabilized with minimal residual dynamic dysfunction and slight oculo-oral synkinesis.…”

“…Its incidence in the literature ranges between 0.07% and 1.4%. [4][5][6] While immediate facial palsy is easily explained by the use of local anesthetics (if transient) or by intraoperative severe surgical trauma (if permanent), many hypotheses have been proposed about the late facial nerve dysfunctions, including reactivation of a quiescent virus colonizing the nerve ganglion. According to Shea et al [4] the most probable etio-pathogenetic mechanism for DFP is the activation of a latent herpesvirus in the geniculate ganglion, induced by mechanical stimulation or reactive inflammation of the facial nerve during middle ear surgery.…”

“…Its incidence in the literature ranges between 0.07% and 1.4%. [4][5][6] While immediate facial palsy is easily explained by the use of local anesthetics (if transient) or by intraoperative severe surgical trauma (if permanent), many hypotheses have been proposed about the late facial nerve dysfunctions, including reactivation of a quiescent virus colonizing the nerve ganglion. According to Shea et al…”

“…This hypothesis has been supported by many other observations after otological surgical procedures [7][8][9][10][11][12][13][14][15][16][17][18] and preventive antiviral therapy has been proposed in patients with positive history to varicella zoster virus and herpes simplex virus 1 and 2. However, serological search of a viral etiology is often inconclusive, not always identifying which virus (HSV type 1, 2, or VZV) is involved; the proposed use of preventive therapy with antivirals in all stapedectomy patients is still debated and often not applied in clinical practice [4][5][6][7] .The purpose of this work is to review the relevant literature on DFP after stapedectomy, aiming at properly assessing the viral etiology and at identifying factors that might influence the prognosis or the recovery time or the choice of therapies, and describe a very unusual case of DFP characterized by VZV reactivation showed by the eruption of typical RH lesions. …”